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Monday, August 22, 2016

ObamaCare in trouble? Coverage, cost, access problems...

I have no doubt you're aware that there's been a lot of fractious, angry news and blog chatter on the Internets lately focused on the broad overlapping topics pertaining to the intractably byzantine business of healthcare. And, as we head for the final approach to the 2016 Presidential election, GOP (and Libertarian) promises to "Repeal and Replace ObamaCare" have never been louder.

While driving home from last my last volunteer stint at Muttville.org, I listened to a very interesting KQED"California Report" segment, one concerning the "mental health" side of things:

Sorry, The Therapist Can't See You — Not Now, Not Anytime SoonMore than 43 million Americans have depression, anxiety, or another mental health condition. But more than half never get help. Recent laws were supposed to make it easier for Californians to access treatment, but many still face roadblocks, even with insurance...We talk to a single mom looking for help in San Francisco, where there are lots of therapists. And we meet a young woman in Shasta County, where there aren’t.

We talk to the therapists who are trying to help. We explore the current state of enforcement. And we take a step back in history to understand how psychotherapy became a hobby of the wealthy rather than a critical service for those in need...

...[Natalie] Dunnege puts all her spare money into therapy for Strazh. She says it helps a lot. But Dunnege herself is struggling, feeling depressed and overwhelmed. She decided to look for her own therapist.

“One of the things that I’ve really had to wrap my head around is that I can’t change him. I can only change how I handle the situation,” she explains. “And not that I would want to change who he is. He’s a really good kid, but it’s a lot to handle, especially as a single parent.”

But when she logged onto her insurance website to find a therapist, she realized her copay for a mental health visit was going to be upwards of $75 – more than double her copay for other doctors’ appointments. Under a 2008 federal mental health law, those copays are supposed to be the same...

More than 43 million Americans suffer from depression, anxiety and other mental health conditions, according to the most recent federal data. But more than half the people who felt like they needed help last year, never got it. Even people who had insurance complained of barriers to care. Some said they still couldn’t afford it; some were embarrassed to ask for help. Others just couldn’t get through the red tape.

But advocates say insurance companies are still finding ways to keep people who need care from getting it. Some are still not complying with the law. And some have found subtle, technically legally, ways to limit treatment... __

There’s something that really bothers Stanford psychiatry professor Keith Humphreys. When he thinks of all the years he spends training the next generation of psychiatrists, the enormous investment in medical school and residency, he wants them to devote that education to taking care of people with serious mental illness.

But many of them instead set up a private practice, where they can charge $400 an hour in cash to help people who Humphreys calls “the worried well” –- people who enjoy the self-exploration of therapy but do not necessarily have a mental health problem...

Aetna’s Obamacare SurpriseDid Aetna just pull a nasty, Trump-like move and up the ante on the Obamacare debate in advance of the election and exchange open enrollment for 2017?

The allegation is that the company withdrew from 11 state insurance exchange marketplaces for 2017 after the Justice Department failed to heed Aetna’s warning that it would do so if Justice didn’t approve its $37 billion purchase of Humana. The Justice Department announced last month that it was challenging that deal and Anthem’s proposed merger with Cigna, saying both deals threaten to sharply reduce competition in the health insurance marketplace...

Value-Based Government (GACRA)We decided that if MACRA is good for physicians, then the same thinking is probably a pretty good idea for the US government. We need Value-Based Government. It’s clear that past methods of paying for US Government services have been terribly inefficient. Costs keep going up. Quality keeps going down. We thought about doing this nationwide, with all US government personnel, but we will just do CMS leaders for now. Let’s call it a demonstration, we’re calling it GACRA, Government Access and CMS Revaluation Act.

Eventually we want all US government employees to be value- based, no more salaries. This is an obvious improvement on how we will pay you, The way you are paid now does not seem to work. Everyone agrees our government is too expensive to run and nothing gets done.

Here’s how value-based government works:

Every CMS leader will send in a code for every 10 or so minutes of work and exactly what they did. Yes, Andy Slavitt and Sylvia Burwell, you will not be paid as you were previously.

You will now be paid for value.

With GACRA, you will need to document every thing you do, but we will only pay for meetings and rules you make.

You will be paid for each meeting in this manner: You need to document the history of the meeting, what you discussed, how complicated the problem is, did you review any prior documentation, did you do an adequate review of the pertinent materials? You will document a level 1,2,3,4, or 5 depending on the complexity, history etc. Don’t document a 4 if it was really a 3, that's fraud, so pay attention, its a complicated formula, but you have time to figure it out...

To document all this, you must use the software that we certify, you cannot use your own. No customized software. We know better on what you need, not you. You may think you have a better way, but forget it. We don’t want innovation or new ideas, we want you to use old, one-size-fits-none software, that they will charge you a lot of money to buy and support. Sorry that its pricey and it doesn’t work well, it is what it is, don’t whine about it...

All of the whiz-bang tech and progressive process QI in the world can be stymied by the Gordian Knot comprising the hopelessly partisan socioeconomic politics of the "Payment Side." See, e.g., my prior posts on the "shards" of health care, here and here. apropos, see also my May 16th post "EHRs and the ACA: Obama's diabolical plot to enslave physicians."

Are insurance policies saving patients money, or keeping them from the treatment they need?As science makes once-unthinkable treatments available, patients are increasingly facing a harsh reality: Insurance companies are forcing them to try older, less expensive therapies for months before covering pricier ones.

Insurers have long relied on a cautious approach to control costs and spare patients from expensive medications they might not need. But in more than a dozen interviews with doctors and patients, a picture has emerged of insurers growing more aggressive as they respond to financial pressures.

The result is a reliance on what is known as “step therapy,” whereby patients are forced to try cheaper treatments before they graduate to more expensive ones, even when health care providers are confident the inexpensive treatments will not work...

This Princeton health economist thinks Obamacare’s marketplaces are doomed@sarahkliffI’ve spent the past week talking to lots of health care experts and economists about the future of the Affordable Care Act. Of all the people I spoke with, Princeton University health economist Uwe Reinhardt offered the most dire and pessimistic assessment of the marketplaces' future.Namely, he believes they’ve already entered a death spiral and are heading toward total collapse...

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"Who knew health care could be so complicated?"

Of ongoing interest

Cogito ergo sum

Will "artificial intelligence" (#AI) soon become simply "intelligence" capable of "reasoning" like humans?

Kind words from Dr. Jerome Carter

"Recently, I have begun reading Bobby Gladd’s KHIT.org blog. His posts (stories? vignettes?) are thoughtful and somehow put into perspective all the nonsense that happens in HIT – informative and thoroughly satisfying."

An American Sickness

On the harmful and persistent fragmentation of health care delivery

On the American way of death

An important book, IMO

The American Association for the Advancement of Science

AAAS.org

The Union of Concerned Scientists

UCSUSA.org

Health 2.0 SF Chapter

Coming soon

I've been around healthcare since 1993. Medicare QIO hospitalization outcomes analyst and network administrator, academic, next-of-kin caregiver (late daughter, late parents), and now, at 71, a Medicare bene having just finished up my own cancer treatment. This book, based in part on the long essay I wrote during my daughter's fatal illness (click Sissy's photo above), will reflect on that multifaceted journey of more than two decades.

An important read with implications for clinical cognition and workflow

Excellent physical neuroscience and neuropsychology findings on the evolution and functionality of the human brain and the adverse impact of information technology.

An impressive, comprehensive resource

NeuroTrainer brain gym

"Train from the neck up."

A very worthy San Franciso organization. I am now a volunteer.

"Lord, may I be HALF the man my dogs think I am."

Healthcare Talent

My friend of more than 20 years and former QIO colleague. Click above for LinkedIn profile page and contact info.

Northern California Cancer Support Community

Serving the Bay Area via the proven "Wellness Community" model established by the late Dr. Harold Benjamin.

An important book by public health expert Vik Khanna

I recently reviewed this book. And, while I don't agree with everything therein, I conclude it to be an important read. It's not a polemical "Repeal ObamaCare" screed at its core, by any means. Vik and I have never met (except for some emails and a Skype call), and I get no compensation for posting this. It's well worth your time.

Brave New Health

Brave New Health Foundation was created to help raise awareness about the important problems in the practice of medicine today. These fundamental problems have been hidden from the public for decades, but they affect everyone -- even you. The current healthcare system leaves patients feeling powerless, medical students overwhelmed, and doctors carrying an impossible burden. This leads to diagnostic errors, bad treatment choices, exploding healthcare costs, and preventable harm.

"Interoperability"?

Commonwell Health Alliance

"For health IT to work, it must be inherently interoperable. There are too many silos across a fragmented information system; vital data is [sic] trapped, creating inefficiency, cost and risk. It’s absolutely critical for interoperability to be built into our health IT systems, not bolted on as an afterthought. What’s more, without interoperability, future innovations in health IT are limited and work only in pockets, rather than benefiting the system as a whole."

BobbyG, ASQ member since 1989

An amazing, inspiring organization

BobbyG on Twitter

BobbyG on Pinterest

Electonic Frontier Foundation

New technologies are radically advancing our freedoms but they are also enabling unparalleled invasions of privacy.

This will never win a Grammy

Published on July 15, 2012: I was inspired to write and record this after the Supreme Court ruling narrowly upholding the PPACA, pejoratively known as "ObamaCare." Thanks to my bro' Lenny Lopez for the harmonies. Thanks to Apple for your awesome GarageBand app. The "Epistemic Hairball All Star Shoe Band" here is nothing but a multitrack sequence of Garageband library loops.

3 Still Standing

I met these folks through my long-time friend Gail Simon, the widow of my 60's bass player the late Jose Simon. Jose went on to co-found the acclaimed "San Franciso Comedy Day in the Park." This is a documentary about the scuffling lives of 3 fine stand-up comics from the era. Produced by award-winning documentary filmmakers Donna LoCicero and Robert Campos. It is very funny, poignantly so.

ThedaCare Center for Healthcare Value

CreateValue.org

Health 2.0

The conference. The media network. The innovation community.

Healthcare Information Management Systems Society

Advancing the best use of information and management systems for the betterment of health care.

International Association of Privacy Professionals

The largest and most comprehensive global information privacy community and resource.

Getting at truth?

Very interesting paper (PDF)

Down in the Weeds'

You owe it to yourself to acquire, study closely, and think hard about this book. For the record; I get nothing from this unsolicited plug. I don't know these people, all I know is what I've read.

SBM

Exploring issues and controversies in the relationship between science and medicine

Another important read (pdf)

I love this kind of stuff. It sustains and humbles me. "As politicians, advertisers, salesmen, and propagandists for various political, economic, moral, religious, psychic, environmental, dietary, and artistic doctrinaire positions know only too well, fallible human minds are easily tricked, by clever verbiage... Common language—or at least, the English language—has an almost universal tendency to disguise epistemological statements by putting them into a grammatical form which suggests to the unwary an ontological statement. A major source of error in current probability theory arises from an unthinking failure to perceive this."

Joe Flower

This book is comprehensive, articulate, learned, and the most charitable of the health policy reform books I've read.

On The Mend

The Lean imperative for health care process improvement, bringing the scientific method into workflow and management. A great read. (Note, I get nothing out of touting this or any other books I cite.)

National Nurses United

MediPedia.com

Growing repository of health-related information, all of it peer-reviewed via the Wiki model

Quotes

"An economist is a person who sees something that works in practice and tries to figure out whether it will work in theory."

- J.D. Kleinke, medical economist___

"The only person who enjoys change is a baby with a wet diaper."

"Every misspent dollar in our health care system is part of somebody's paycheck.

- Brent James, M.D., M.Stat

“We could do healthcare, at markedly higher quality, for everyone in this country, without rationing or denying anybody the care that they need, without having the government dictate how doctors practice or whether hospitals could expand, at half the cost we do it now.”

- Health Care Futurist Joe Flower

Most of the sciences, unlike parts of medical science, are not concerned with the impossible. There is not complementary and alternative physics, or chemistry, or biochemistry, or engineering. These disciplines compare their ideas against reality, and, if the ideas are found wanting, abandoned."

- Mark A. Crislip, MD

"Q: How much alcohol is too much?A: More than your doctor drinks."

- a physician I once heard speak during a CME presentation

“Just because science doesn’t know everything, doesn’t mean you get to fill in the gaps with whatever fairy tale most appeals to you.”

- Dara O’Briain

'[I]t is one small step from using the computer for "helping" doctors to monitoring them, judging them, dictating to them what to do, and withdrawing payment for computer non-compliance. The use of computer data is a multi-edged sword. It can be used for the "good," facilitating diagnosis and treatment and making it more accurate and up-to-date, and for “evil,” invading privacy, inviting security breechs, and making decisions based on the opinions of remote authorities rather than those present at the patient-doctor encounter.'

- Richard Reece, MD

“[T]here ARE statistics which are non-political. Just because The Washington Post/Fox News reports the temperature is 75 degrees doesn’t mean it’s really snowing and sunscreen is a liberal/conservative plot. Even if you earn a living being ideological.”

- Michael L. Millenson

"It is a generally a fairly convincing argument that people shouldn’t have to be subsidized to undertake a change which is in their best interest.

The reconciliation seems to be that EHR is not supposed to make a doctor’s practice more efficient and higher quality. It is supposed to make the system of care more efficient and higher quality, which is not the same thing. Those of you who took calc recall that maximizing the total of variables is not achieved by maximizing any one variable and this is a perfect example of that.

Those of you have served in combat certainly noticed that too — if everyone works as a team the unit takes fewer casualties. If you try to save your own hide, you might, but at the expense of more casualties overall."

- Al Lewis

"There are two ideas to keep in mind about Bayesian reasoning and how we tend to mess it up. The first is that base rates matter, even in the presence of evidence about the case at hand. This is often not intuitively obvious. The second is that intuitive impressions of the diagnosticity of evidence are often exaggerated."

- Daniel Kahneman, "Thinking, Fast and Slow"

"Physicians apply advanced scientific knowledge, but they must do so without the favorable conditions that experimental scientists create for themselves. Multitasking is forced on physicians, often in chaotic environments and under severe time and resource constraints."

- Lawrence and Lincoln Weed, "Medicine in Denial"

"It’s time to stop the whining about Obama care and acknowledge we already have universal health care. We just pay for it in the stupidest way possible that ensures problems are that much more disastrous and complicated when they’re finally treated."

- Mark Hoofnagle, MD, PhD

"Every act of conscious learning requires the willingness to suffer an injury to one's self-esteem. That is why young children, before they are aware of their own self-importance, learn so easily."

- Thomas Szasz, MD___

"Of course, one reason that process metrics* are so popular is that processes are much easier to define and measure than outcomes."

- The Skeptical Scalpel___

"There is an “illusion of validity” for any random data point, a seductive sense that is colored by what we hope will be true. Mountains of pharmaceutical claims are often made from mere molehills of data."

- Danielle Ofri, MD___

"Joy empowers people. It is a source of energy that enables people to hope and plan and change their lives for the better. Spend some time around someone who is relentlessly negative and how do you feel–drained, right? More and more research shows that joy is not something that just happens to you, like a bolt of lightening out of the blue. Joy is, instead, a habit to cultivate. Negative thinking and despair are the crabgrass of our souls–weeds that take root and spread, sometimes to all areas of life. Joy, in contrast, is a soul’s rose–hardy when cared for, able to put down roots over time and withstand disease and extremes. Like a rose, however, your joy can become blighted from neglect or harsh conditions. We all need to tend to our joy–to prune away the badness, and to know that, even though it may look like a prickly bare root, if you invest time in a joyous outlook, gorgeous things will bloom, even in the harshest conditions."- Dr. Jan Gurley___

"'Solutions' exist only in mathematics."

- Karen Martin___"The issue of how to regulate clinical software is, in the long run, indistinguishable from the issue of how to regulate medicine. The only difference is that medicine is practiced in the open, without secrecy, subject to peer review, and under a merit-based state license."

About Me

Cheryl D. Prince, CQA, CMQ/OE

Corporate Director of Quality, Gilbane Building Company, Concord, CA. My wife and best friend of more than four decades. Scary smart. The kindest person I ever met.

DISCLAIMER:

I write this blog wholly on my own time and my own dime. The views proffered are expressly my own as a concerned and active citizen/taxpayer (in addition to being the result of my substantive experience in the various IT fields), and in no way reflect any policy views of my former employer, notwithstanding that some of the thinking has indeed obviously been spurred by the implications of the work with which I have been doing for them.

FAIR USE POLICYI cite a ton of news and web sources spanning the breadth of relevant technical and policy domains, sometimes at substantial length. I believe I remain well within the bounds of "Fair Use," as [1] I am not doing any of this for profit, [2] I always provide attribution and links -- which, [3] far from negatively impacting any copyright holders' commercial interests, might actually increase traffic to and interest in their offerings.

Nonetheless, should I post anything of yours regarding which you have any objection, just let me know and I will remove it forthwith.